Gestational trophoblastic disease (GTD) refers to abnormal cell growth that starts in the placental cells, ranging from benign conditions like molar pregnancies to malignant cancers like choriocarcinoma. GTD is diagnosed through symptoms like vaginal bleeding, enlarged uterus, and high hCG levels and treated with surgery, chemotherapy, or follow-up monitoring depending on whether the condition is benign, low risk, or high risk metastatic cancer. Prognosis is generally good even for metastatic GTD if treated early, though choriocarcinoma can be life-threatening if spread to vital organs occurs.

1. GESTATIONAL
TROPHOBLASTIC
DISEASE

2. GESTATIONAL TROPHOBLASTIC
DISEASE
Gestational → pregnancy
Tropho → nutrition
Blast → bud/early developmental cell
GTD → begins in the layer of cell called trophoblast
that normally surrounds an embryo.
The term gestational trophoblastic disease refers to
pregnancy-related trophoblastic proliferative
abnormalities.

3. INTRODUCTION
GTD:
• Abnormal growth of cells inside a women’s
uterus.
• Dont develop from cells of uterus.
• Starts in the cells that would normally develop
into placenta.
• Most GTD’s are benign, some are cancerous.

4. GTD
• BENIGN
• Hydatidiform mole
• MALIGNANT
• Invasive mole
• Choricocarcinoma
• Placental site trophoblastic
tumor
• Epithelioid trophoblastic
tumor

5. Relationship of HM. IM. CH
hydatidiform therapeutic or
mole spontaneous abortion
term pregnancy
ectopic
invasion mole choriocarcinoma.

6. HYDATIFORM MOLE
It is a neoplastic proliferation of the trophoblast in which
the terminal villi are transformed into vesicles filled with
clear viscid material.

7. BENIGN
Empty egg
↓
fertilizes by paternal X’s only
↓
46 XX (diploidy)
Fetus absent
20% → malignancy
No chemo,serum beta hCG
(-ve) f/u 1 year on OCPs.
INCOMPLETE MOLE
Normal egg
↓
Maternal & paternal X’s
↓
69XXY(triploidy)
Fetus non viable
10% → malignancy
No chemo,serum beta hCG(-ve)
f/u 1 year on OCPs.
COMPLETE MOLE

8. COMPLETEHYDATIDIFORM MOLE
• The entire uterus
filled with
abnormal vesicles,
no signs of fetus

9. PARTIAL HYDATIDIFORM
MOLE
Partial
hydatidiform
mole with
evidence of a
conceptus.

10. MALIGNANT
NON METASTASIS GOOD PROGNOSIS POORPROGNOSIS
↓ ↓ ↓
Uterus only pelvis/lungs brain/liver
100% cure > 95% cure 65% cure
SINGLE AGENT CHEMOTHERAPY MULTIPLE AGENT
1Y,F/U ON OCS AFER β hCG(-ve) CHEMOTHERAPY
5 Y F/U ON OCS AFTER
βhCG (-ve)

11. ETIOLOGY
Though it is not known a number of associated factors
have been noted:
the absence of fetal circulation;
dietary protein deficiency
viral infection;
age:>45 years women are 10 times more likely to
develop HM than those younger

12. abnormal fertilization process:
the fertilization of a normal ovum with a
duplicated haploid sperm:46XX
the fertilization of an empty egg by two
sperms(dispermy):46XY

13. Epidemiology
• The antecedent pregnancy is :
Hydatidiform mole in about 57% of
cases.
Normal pregnancy in about 26% of
cases.
Abortion and ectopic pregnancy in
about 17% of cases.

14. Pathological features
Site: In the uterus 90% of
cases; 10 % of cases in the
ovaries ,vagina, vulva, lung,
liver, and brain.

15. Pathological features
• Macroscopically:
Uterus: It may be localized in the form of
hemorrhagic polyp or multiple hemorrhagic
,necrotic masses in the cavity.
 Some times it is present in the uterine
wall (intramural) and the cavity is empty.

16. Pathological features
Ovaries : May show stormal
lutein hyperplasia, and theca-
lutein cysts. And may be site of
secondaries.

17. Pathological features
• Microscopically:
Malignant hyperplasia of both
cytotrophoblasts,and syncytiotrophoblasts.
Extensive hemorrhage.
Absence of villi.
Destruction of the surrounding myomatrum.

18. Spread
• Blood : The main method of spread ,and occurs
to;
Genital : Vagina, vulva, and ovary.
Extra genital : Lung, liver, brain, and bones
especially skull and spine.
The lung is the commonest site for secondaries
and haemoptysis may be the presenting
symptom.

19. Causes of death
• Vaginal bleeding.
• Haemoptysis.
• Intraperitoneal hemorrhage.
• Peritonitis.
• Metastasis to the vaital organs e.g,brain.
• Pulmonary complications.

20. RISK FACTORS
i) Women age being under 20 years ,above 35
years of age.
ii) Previous GRD
iii) Being asia/ asian ethinicity
iv) Abo blood groups of parents appear to be a
factor-choriocarcinoma
v) Women with blood group A is higher risk
than o

21. • Persistent GTD should be
considered in any woman
developing:
acute respiratory or neurological
symptoms after any pregnancy.
CLINICAL FEATURES

22. Clinical features
The clinical classification of gestational
trophoblastic disease:
I. Non-metastatic.
II. Metastatic:
A. Low risk: All patient of documented
metastatic disease who do not have “high-
risk factors”.

23. B.High risk:
1. B-hCG level higher than
100.000miu/ml.
2. Associated pregnancy episode
more than 4 months before the
diagnosis.

24. ENLARGED UTERUS

25. DIAGNOSIS
i) Vomiting too much( hyperemesis)
ii) Vaginal bleeding
iii) Enlarged uterus before expected dates
iv) Hypertension
v) ↑ serum βhCG
vi) Pelvic discomfort
vii) Blood tests
viii)Ultrasound
ix) Proteinuria(2+)

26. PERSISTENT TROPOBLASTIC
DISEASE
• Gtd that is not cured by initial surgery.
• Mole grown from the surface layer of uterus
into the muscular layer below(myometrium)
• Can spread withi n the body like a malignant
cancer
• Treatment → chemotherapy

27. Treatment
• Prophylaxis: After care of vesicular
mole;
 D&C after one week of the
evacuation.
 Monitored for the signs and symptoms of
trophoblastic neoplassmic by:.
I. serial hCG.

28. II. Diagnostic D&C is done if :
 The hCG levels remains high.
 The hCG levels rises after gets negative.
 Uterine sub involution.
 Persistence of theca lutein cysts in the
ovaries.
 Every case of secondary postpartum
haemorrhage.
 Every case of post abortive bleeding.

29. Active treatment
I. Non metastatic GTD:
o Methotrexate (antimetabolite) +folinic
acid.
o The cytotoxic therapy is controlled by
doing CBC,platelet count and LFT.
o After the the hCG level gets normal
;stop the therapy and follow-up by
weekly estimation of hCG levels.

30. Active treatment
• Women scoring: Non metastatic
GTD,and(low risk) GTD receive
intramuscular methotrexate on
alternate days, followed by six rest
days, with each course consisting of
four injections

31. Activetreatment
o Physical examination, chest x-ray,
and LFT.
o Total abdominal hysterectomy ,if the
patient does not desire to maintain
child-bearing, in the middle of the
first treatment course .

32. II.Low metastatic GTD:
o Methotraxate , or Actinomycin D
,if there is resistance ,change to
triple chemotherapy.

33. III.High risk metastatic GTD :
o Triple chemotherapy :
Methotraxate,
Actinomycin D, and
Cytoxan.

34. Follow-up
• After successful therapy ,the hCG levels
are obtained :
every 2weeks for 3 months,
 every month for 3months,
every 2months for 6 months then every
sixes months indefinitely.

35. Follow-up
• If at any time hCG levels rises, repeat
the evaluation , staging ,and
chemotherapy.
• Physical examination, and chest x-ray
follow-up at 6 weeks, then every
3months for one year, then every 6
months for one year.

36. Future pregnancy
• If a further molar pregnancy does occur,
in 68–80% of cases it will be of the
same histological type

37. • Women who undergo chemotherapy
are advised not to conceive for one
year after completion of treatment

38. INVASIVE MOLE
• Hydatidiform mole : grown into →muscular layer
of uterus .
• Develop from both complete (common)& partialmoles.
• Develop in a little less than 1 out of 5 women who had a
complete mole removed.
• Risk:Women> 40 years ,has had GTD in the past.
• Sometimes go away on their own,bt most often more treatment
is needed.
• A tumor/mole that grows completely through the wall of uterus
may result in bleeding into abdominal/pelvic cavity;this can be
life threatening.

39. CHORIOCARCINOMA
• Malignant form of GTD.
• Develops from: complete(common)&partial moles,
normal pregnancy, miscarriage.
• Rarely can develop that are not related to
pregnancy(areas other than uterus)
• Develop in ovaries ,testicles, chest or abdomen.
• These cases :it is mixed with other types of cancer
→mixed germ cell tumor.

40. PLACENTAL SITE
TROPHOBLASTIC TUMOR
• Very rare form of GTD
• Develops: placenta attaches the lining of uterus.
• Develops after:normal pregnancy/abortion but may
develop after a complete/partial mole.
• Most of them don’t spread to other parts of body.
• Tendency to grow(invade) the muscular layer of uterus.
• Insensitive to chemo drugs,surgery is aimed at completely
removing the disease.

41. TREATMENT
i)Evacuation of pregnancy : relief of symptoms
prevent complication
Suction curettage is prefered method of evacuation.
ii) Hysterectomy : if no other pregnancy is wished
by the patient.
iii)Chemotherapy drugs : methotrexate (IV) systemic.
iv) Advised not to get pregnant for 1 year after
completion of treatment.

42. MOLAR PREGNANCY
QUESTIONS
• History
• Exam
• Sonography
• Pre-operative working
• Histology benign
• Histology malignancy
DIAGNOSIS,MAGNT:
• Bleeding ,nausea& vomiting
→vesicles
• Fundus> before date
→no Fetal heart tone
• Snowstorm fetus absent
→honey coomb,fetus present
• hCG tilter serum,chest x ray
→suction empty the uterus
• Complete &incomplete H.moles
→hCG tilter
• Good&poor prognosis
→single& multiplechemotherapy

43. PROGNOSIS & STAGING
• Women with a hydatidiform mole have an
excellent prognosis.
• Choriocarcinoma →→ highly malignant tumor life
threatening.

44. Patient compliants ????
Vaginal bleeding…passage of
grapes(villi ie vesicles)
• Hyperemesis
• No fetal sounds(tone)
• Uterus extends to her
umbilicus before
dates(20wks)
• proteinuria,(2+)
• Hypertension(140/90)